Healthcare Provider Details

I. General information

NPI: 1033900451
Provider Name (Legal Business Name): PBJ MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/15/2025
Last Update Date: 05/15/2025
Certification Date: 05/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 MAITLAND AVE
ALTAMONTE SPRINGS FL
32701-6834
US

IV. Provider business mailing address

7512 DR PHILLIPS BLVD STE 50
ORLANDO FL
32819-5420
US

V. Phone/Fax

Practice location:
  • Phone: 800-485-7962
  • Fax:
Mailing address:
  • Phone: 800-485-7962
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: DR. KEVIN PRUITT
Title or Position: LAB DIRECTOR
Credential: MD, PHD
Phone: 800-485-7962